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TUIP — Transurethral Incision of the Prostate

Transurethral Incision of the Prostate (TUIP) is a short procedure for bladder outlet obstruction in men with small prostates.[1] Wei 2025 lists a prostate size of ≤30 g for TUIP, whereas EAU 2026 recommends it for prostate volume <30 mL without a middle lobe.[4][20] Randomized trials of mostly moderate-to-poor quality found no clear difference in patient-reported symptom improvement at 12 months.[1][11] TUIP had shorter operations and hospital stays, less perioperative transfusion and retrograde ejaculation, but more reoperations in the 2010 synthesis.[1] The AUA 2026 guideline states that clinicians may offer TUIP for prostates < 30 cc without a median lobe .[19] TUIP or bladder neck incision is also used for primary bladder neck obstruction (PBNO), especially in younger men.[5][6] For positioning against other BPH options, see BPH & Male LUTS — chooser.

Mechanism​

Unlike TURP, which removes tissue, TUIP works by incising the bladder neck and prostatic urethra without removing prostatic tissue. As the incisions are deepened through the prostatic capsule, the bladder neck and prostatic urethra spring open, relieving the circumferential compression that causes obstruction.[2][7] The tissue splays apart, widening the channel, much as a tight ring does when it is cut. No tissue is resected and no specimen is available for histological analysis.[8]

Procedure​

TUIP is performed under regional or general anesthesia. Operative time is typically 10–20 min.[2][3][9]

  1. Standard resectoscope (or cystoscope with Collins knife or Collings electrode) into the prostatic urethra.
  2. Identify interureteric ridge (proximal limit), verumontanum (distal limit), and ureteral orifices.
  3. Incision technique:
    • Single incision at the 6 o'clock position from just distal to the interureteric ridge to the verumontanum, deepened through prostatic tissue until the surgical capsule or periprostatic fat is reached.[7][9]
    • Double incision at the 5 and 7 o'clock positions with the same proximal-to-distal trajectory; more commonly described in the literature.[2]
  4. Deepen with electrocautery (monopolar or bipolar) or holmium:YAG laser until the bladder neck visibly springs open.
  5. Hemostasis with coagulation.
  6. Foley catheter placed; often removed within 24 hours, or omitted entirely with laser TUIP.

Energy sources​

  • Monopolar electrocautery (Collins knife): traditional approach.
  • Bipolar electrocautery with saline irrigation avoids the TUR-syndrome risk of monopolar current.
  • Holmium:YAG laser. In a prospective series of 100 men with glands < 30 g (Cornford 1998), 97 voided without postoperative catheterization. IPSS fell from 19.2 to 3.7 and Qmax rose from 9.8 to 19.2 mL/s at 6 weeks, and both remained improved at 2 yr. All 77 men who were potent preoperatively remained potent, and 8 men developed retrograde ejaculation.[10] In a separate 140-man randomized trial of holmium versus monopolar bladder-neck incision for prostates no larger than 30 cc, symptom and flow outcomes were comparable through 12 months, but retrograde ejaculation was more frequent with holmium (22.9% vs 6.1%; p = 0.02); reported postoperative hematuria was 0% versus 4.2%.[22]

Patient selection​

TUIP suits a specific subset of men with BPH[2][8][4]:

  • Prostate volume <30 mL without a median lobe. For LUTS/BPH, AUA 2026 gives this as a Clinical Principle, and EAU 2026 makes a Strong recommendation for moderate-to-severe LUTS attributed to benign prostatic obstruction.[19][20] Older trials used varied prostate-size upper limits.[1] The 2001 meta-analysis found no clear cutoff above which results fell off.[11] EAU cites a six-trial meta-analysis in which reoperation was more common after TUIP than M-TURP (18.4% vs 7.2%); no TUIP TUR-syndrome cases were reported.[20]
  • Moderate-to-severe LUTS attributed to benign prostatic obstruction. For young men with suspected PBNO or dysfunctional voiding, EAU 2026 weakly recommends videourodynamics either initially or after failed first-line therapy.[19][20]
  • No median lobe for LUTS/BPH. The AUA 2026 Clinical Principle and EAU 2026 Strong recommendation specify this selection criterion; the cited recommendations apply to prostates without a median lobe.[19][20] Before selecting TUIP, measure prostate volume by imaging and assess middle-lobe anatomy by urethrocystoscopy when it may change treatment .[20]
  • Primary bladder-neck obstruction (PBNO). Incision is an established treatment, particularly in younger men (mean age approximately 40 yr) in whom alpha-blockers gave inadequate relief.[5][6]
  • Ejaculatory-preservation priority. Retrograde ejaculation is less frequent after TUIP than after TURP.[3][11] In one 35-man PBNO series of unilateral incision, mean sperm concentration fell 63% at 6 months and 69% at 1 year.[17] In a retrospective PBNO sperm-bank cohort, 5/65 men reported anejaculation and 25 paired semen samples showed a lower total sperm number at a median 12 months after incision.[23] Discuss preoperative semen analysis and sperm cryopreservation with men seeking future paternity.[23]
  • Can be performed as an outpatient procedure.[8]

Clinical efficacy​

Yang 2001 and Lourenco 2010 systematic reviews — TUIP vs TURP​

Yang 2001 pooled 9 RCTs. Lourenco 2010 pooled 10 RCTs (795 participants) of moderate to poor quality.[11][1]

  • Symptom improvement was equivalent at 12 mo.[11][1]
  • Qmax improvement was greater with TURP (+112% vs +76% with TUIP in the pooled data cited by Oesterling).[2]
  • TUIP had shorter operative time and shorter length of stay.[11][1]
  • Reoperation at 12 mo was equivalent in Yang 2001. Lourenco 2010 found a higher reoperation rate after TUIP, and Yang 2001 noted little evidence beyond 12 mo.[11][1]

Riehmann 1995 RCT — 120 randomized, 112 evaluated at a mean of 34 mo[3]​

  • No significant difference in irritative / obstructive / total symptom scores at any visit.
  • Qmax higher (not statistically) with TURP.
  • Among men sexually active before and after surgery, retrograde ejaculation developed in 15/22 (68%) after TURP and 8/23 (35%) after TUIP (p = 0.020).[3]
  • Further treatment for BPH-related obstruction occurred in 9 TURP patients (16%) and 14 TUIP patients (23%); the difference was not significant (p = 0.908).
  • The authors concluded that in small prostates (estimated resectable weight < 20 g) TURP and TUIP were generally equally effective, and called TUIP "an underutilized procedure".

Christensen 1990 RCT — 93 patients enrolled to date, single 6 o'clock incision[9]​

  • 80–90% of patients in each arm reported improvement at 3 mo. Prostates were estimated at ≤ 20 g.
  • No significant difference in symptom scores or Qmax.
  • OR time, blood loss, catheter duration, LOS all significantly favored TUIP.
  • Loss of ejaculation was reported by 37% after TURP versus 13% after TUIP, not statistically significant in this sample.[9]

Sirls 1993 long-term — 41 patients, mean 53 mo[12]​

  • Significant decrease in total / obstructive / irritative scores (p < 0.05).
  • Four men reported new retrograde ejaculation (11% as reported by the authors).[12]

Comparison figures attributed to Wei 2025 JAMA review[4]​

ParameterTUIPTURP
Prostate size reported by Wei 2025[4]≤ 30 g<80 g
IPSS Δ−12.7 at 48 mo−15.1 at 12 mo / −13.2 at 60 mo
Qmax Δ+8.2 mL/s at 48 mo+10.6 mL/s at 12 mo / +6.3 mL/s at 60 mo
5-yr retreatment13%7.7%
Incontinence (0–3 mo)0–2%0–5%
Erectile dysfunction8%14%
Retrograde ejaculation22%60–75%

Retreatment and durability — TUIP's principal limitation​

SourcePopulationFollow-upRetreatment
He 2023 SR130,106 patients across BPH procedures; TUIP: 90 men in two studies[13]5 yrSeparate pooled surgical retreatment estimates: TUIP 13.4% (95% CI 6.9–21.5%; 2 studies), TURP 7.7% (13 studies), HoLEP 6.6% (7 studies), Aquablation 4.1% (2 studies).
Lourenco 2010 SR10 RCTs, 795 patients[1]up to several yearsHigher reoperation rate after TUIP than TURP
Page 2025 NHS England retrospective study155,874 patients[14]5-yr reintervention analysis (2012–2022 study period)Less invasive treatments, which included TUIP, were associated with more reintervention than TURP but lower odds of in-hospital complications
Katz 1990 single-incision series66 pts; outcomes available in 64[7]mean 2.24 yrSubsequent TURP 5/66 (7.6%)

Safety profile​

TUIP carries lower rates of transfusion and TUR syndrome than TURP. Urinary retention, UTI, stricture and incontinence did not differ significantly between the two, although clinically important differences could not be excluded.[2][11][1]

ComplicationTUIPTURP
Transfusion1%6%
TUR syndromeNo cases recorded0.8% (M-TURP comparator RCTs)
Impotence / ED (JAMA review estimates)8%14%
Retrograde ejaculation (JAMA review estimates)22%60–75%
Incontinence at 0–3 mo (JAMA review estimates)0–2%0–5%
UTIsimilarsimilar
Urethral stricturesimilarsimilar
Urinary retentionsimilarsimilar
Mortality—0.1% at 30 days after M-TURP[20]

Sexual function — TUIP's defining advantage​

  • Across four early RCTs, retrograde ejaculation occurred in 15% after TUIP and 66% after TURP.[2] The AUA 2026 guideline cites 18.2% vs 65.4%.[19]
  • Riehmann RCT: 35% versus 68% (p = 0.020).[3]
  • In a single-incision series (Katz 1990), antegrade ejaculation was preserved in 83.3% of men who had it preoperatively.[7]
  • After holmium-laser TUIP (Cornford 1998), 8 men developed retrograde ejaculation.[10]
  • At a mean follow-up of 53 mo (Sirls 1993), 4 men reported new retrograde ejaculation (11% as reported by the authors).[12]
  • Pooled impotence: 2% TUIP versus 5% TURP.[2]

Proposed mechanism of preservation. TUIP makes one or two discrete incisions through the bladder neck. TURP resects the bladder neck circumferentially.[15] Sparing bladder-neck circular muscle has been proposed as one explanation for preserved antegrade ejaculation after TUIP, but the cited review emphasizes peri-verumontanal tissue preservation.[15]

Ejaculation-Sparing Bladder Neck Incision (ESBNI)​

Sinha 2026 was a retrospective cohort with prospective outcome assessment of men ≤ 40 years with videourodynamically confirmed PBNO. A single 6 o'clock incision with the distal extent limited to approximately 10 mm proximal to the verumontanum preserved antegrade ejaculation in all 51 men with available data (51/51 of 53 treated) at a median follow-up of 13 mo; 90% of those assessed had normal ejaculatory function. Median postoperative Qmax was 17 mL/s, and 18 of 19 catheter-dependent patients became catheter-free. Three patients required redo surgery.[16]

TUIP for primary bladder-neck obstruction (PBNO)​

In a 36-man PBNO series, mean age was 41 yr; patients presented with LUTS, decreased flow and elevated voiding pressures localized to the bladder neck on video-urodynamics.[5] EAU 2026 weakly recommends considering alpha-blockers first-line in young men with PBNO; for well-informed young men with PBNO unresponsive to alpha-blockers, it weakly recommends considering bladder-neck incision or intermittent catheterization.[20] The AUA 2026 guideline states that clinicians may offer TUIP, transurethral resection of the bladder neck or a temporary implantable prostate device in suspected PBNO , and notes that long-term data are limited.[19] Across PBNO surgical studies summarized by EAU 2026, reported ejaculatory dysfunction ranged from 0% to 88.8%; the pooled estimate after bladder-neck incision was 3.0% (95% CI 1–6%).[20]

SeriesnKey finding
Trockman 1996[5]36 (mean age 41); 18 underwent incisionRetrospective review. In the 18 men who underwent incision, symptom scores, Qmax, PVR and voiding pressures improved significantly, with a mean 87% overall symptom improvement. Only 30% of men who started alpha-blockers continued them long term, usually because of inadequate relief.
Kaplan 1994[6]34 (age 26–51) treated as chronic nonbacterial prostatitis; 31 had bladder-neck obstruction on urodynamicsIncision at 5 o'clock from the bladder neck to the verumontanum; marked improvement in 30 of 31 and Qmax 9.2 to 16.4 mL/s at 3 mo. All 31 reported postoperative antegrade ejaculation.
Kochakarn 2003[17]35 (mean age 40)Unilateral incision: 55% IPSS reduction and 95% Qmax improvement at 1 yr. Sperm count fell 63–69% to 18–21 million/cc, which the authors considered probably sufficient for fertility.

For this high-bladder-neck pattern, a single incision is more often placed at the 7 or 8 o'clock position rather than 6 o'clock, or paired incisions at the more lateral 4 and 8 o'clock positions in addition to the classic 5 and 7 o'clock pair; lateral positioning is thought to let the bladder-neck tissue spring apart more than a midline cut. The incision starts about 0.5–1 cm inside the bladder and is carried to the proximal verumontanum, staying lateral throughout its distal course. No controlled comparison of incision angle has been reported.[21]

Holmium-laser TUIP vs GreenLight PVP for small prostates​

A retrospective review of a prospectively maintained database compared 47 holmium TUIP and 144 GreenLight PVP procedures in men with prostates < 40 mL.[18]

  • Holmium TUIP had a shorter operative time (30 vs 46 min) and a longer hospital stay (0.8 vs 0.3 d) and catheter duration (1.3 vs 0.4 d).
  • IPSS, QoL, PVR and Qmax improvements were comparable at 1 and 5 yr.
  • Reoperation was 6.4% after TUIP and 10.4% after PVP (not significant).
  • Mean estimated cost per procedure was lower for holmium TUIP ($509 CAD vs $1,766 CAD, p = 0.002).

Where TUIP fits in 2026​

StrengthLimitation
Similar 12-mo symptom improvement to TURP in older trials[1]Guideline indication: prostate volume <30 mL, no median lobe[19][20]
Lower reported retrograde ejaculation estimates (22% TUIP; 60–75% TURP)[4]Five-year surgical retreatment estimates from separate study groups: 13.4% TUIP (2 studies) and 7.7% TURP (13 studies)[13]
Short operative time (10–20 min)No tissue for histological analysis
Outpatient feasibilityDoes not address median-lobe obstruction
Lower perioperative morbidity (negligible transfusion risk and no recorded TUIP TUR syndrome cases)[20]Smaller Qmax improvement than TURP
Option for suspected PBNO [19]Used less often than TURP
Low cost, especially with holmium laser (one Canadian series)Limited long-term data

Randomized trials, most of moderate to poor quality, found TUIP and TURP equivalent for symptom relief in small prostates over the first year, and the authors of one trial described TUIP as underutilized.[3][11][1] For LUTS/BPH, the 2026 AUA and EAU criteria specify prostate volume <30 mL without a median lobe.[19][20] In eligible men, ejaculatory preservation may favor TUIP over TURP.[3][11] PBNO has a separate diagnostic and treatment pathway.[20] It competes for the ejaculation-sparing role with UroLift, Rezūm and iTIND. TUIP requires anesthesia and carries a higher retreatment rate than TURP.

See Also​

BPH & Male LUTS — chooser · TURP · AEEP (HoLEP / ThuLEP / ThuFLEP / BipolEP) · Aquablation · GreenLight PVP · UroLift · Rezūm · iTIND · Optilume BPH · PAE · Simple Prostatectomy

References​

1. Lourenco T, Shaw M, Fraser C, et al. The clinical effectiveness of transurethral incision of the prostate: a systematic review of randomised controlled trials. World J Urol. 2010;28(1):23-32. doi:10.1007/s00345-009-0496-8

2. Oesterling JE. Benign prostatic hyperplasia — medical and minimally invasive treatment options. N Engl J Med. 1995;332(2):99-109. doi:10.1056/NEJM199501123320207

3. Riehmann M, Knes JM, Heisey D, Madsen PO, Bruskewitz RC. Transurethral resection versus incision of the prostate: a randomized, prospective study. Urology. 1995;45(5):768-775. doi:10.1016/S0090-4295(99)80081-8

4. Wei JT, Dauw CA, Brodsky CN. Lower urinary tract symptoms in men. JAMA. 2025;334(9):809-821. doi:10.1001/jama.2025.7045

5. Trockman BA, Gerspach J, Dmochowski R, et al. Primary bladder neck obstruction: urodynamic findings and treatment results in 36 men. J Urol. 1996;156(4):1418-1420. doi:10.1016/s0022-5347(01)65605-2

6. Kaplan SA, Te AE, Jacobs BZ. Urodynamic evidence of vesical neck obstruction in men with misdiagnosed chronic nonbacterial prostatitis and the therapeutic role of endoscopic incision of the bladder neck. J Urol. 1994;152(6 Pt 1):2063-2065. doi:10.1016/s0022-5347(17)32309-1

7. Katz PG, Greenstein A, Ratliff JE, Marks S, Guice J. Transurethral incision of the bladder neck and prostate. J Urol. 1990;144(3):694-696. doi:10.1016/s0022-5347(17)39557-5

8. Arnold MJ, Gaillardetz A, Ohiokpehai J. Benign prostatic hyperplasia: rapid evidence review. Am Fam Physician. 2023;107(6):613-622. PMID 37327163

9. Christensen MM, Aagaard J, Madsen PO. Transurethral resection versus transurethral incision of the prostate. A prospective randomized study. Urol Clin North Am. 1990;17(3):621-630. doi:10.1016/s0094-0143(21)00975-7

10. Cornford PA, Biyani CS, Powell CS. Transurethral incision of the prostate using the holmium:YAG laser: a catheterless procedure. J Urol. 1998;159(4):1229-1231. doi:10.1016/s0022-5347(01)63566-3

11. Yang Q, Peters TJ, Donovan JL, Wilt TJ, Abrams P. Transurethral incision compared with transurethral resection of the prostate for bladder outlet obstruction: a systematic review and meta-analysis of randomized controlled trials. J Urol. 2001;165(5):1526-1532. doi:10.1016/s0022-5347(05)66342-2

12. Sirls LT, Ganabathi K, Zimmern PE, et al. Transurethral incision of the prostate: an objective and subjective evaluation of long-term efficacy. J Urol. 1993;150(5 Pt 2):1615-1621. doi:10.1016/s0022-5347(17)35858-5

13. He W, Ding T, Niu Z, et al. Reoperation after surgical treatment for benign prostatic hyperplasia: a systematic review. Front Endocrinol. 2023;14:1287212. doi:10.3389/fendo.2023.1287212

14. Page T, O'Toole E, Keltie K, et al. Surgery for benign prostate enlargement in England: 10-year retrospective study of 155,874 patients. BJU Int. 2025;136(1):109-119. doi:10.1111/bju.16713

15. Couteau N, Duquesne I, Frédéric P, et al. Ejaculations and benign prostatic hyperplasia: an impossible compromise? A comprehensive review. J Clin Med. 2021;10(24):5788. doi:10.3390/jcm10245788

16. Sinha S, Lakhani D, Prasad CR. Ejaculation sparing bladder neck incision for young men with primary bladder neck obstruction. Int J Urol. 2026;33(5):e70478. doi:10.1111/iju.70478

17. Kochakarn W, Lertsithichai P. Unilateral transurethral incision for primary bladder neck obstruction: symptom relief and fertility preservation. World J Urol. 2003;21(3):159-162. doi:10.1007/s00345-003-0343-2

18. Elshal AM, Elkoushy MA, Elmansy HM, Sampalis J, Elhilali MM. Holmium:YAG transurethral incision versus laser photoselective vaporization for benign prostatic hyperplasia in a small prostate. J Urol. 2014;191(1):148-154. doi:10.1016/j.juro.2013.06.113

19. Goueli R, Badlani GH, Welliver C, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA guideline (2026). Part III: Procedural and surgical management. J Urol. 2026;216(2):161-170. doi:10.1097/JU.0000000000005099

20. European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male LUTS. 2026 (March update). Official full guideline. See section 5.3.1.d.

21. Robles J. Transurethral Resection and Transurethral Incision of the Prostates. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:461–468.

22. Bansal A, Sankhwar S, Kumar M, et al. "Holmium Laser vs Monopolar Electrocautery Bladder Neck Incision for Prostates Less Than 30 Grams: A Prospective Randomized Trial." Urology. 2016;93:158-163. doi:10.1016/j.urology.2016.03.042

23. Hirsch MN, Pallotti F, Faja F, et al. "Bladder Neck Obstruction: Experience and Management in a Sperm Bank." Life (Basel). 2023;13(3):842. doi:10.3390/life13030842